A Healthier Ontario

PATHS TO PROSPERITYA H E A LT H I E R O N TA R I O

A n O n t a r i o P C C a u c u s W h i t e P a p e r

F e b r u a r y 2 0 1 3

Of all the services we expect from government, health care is the most personal. Our encounters with health care can be the most joyful and the most sorrowful of our lives – the birth of a child, the death of a parent, a diagnosis of cancer or the news of a complete recovery.

Health care in Ontario today has tremendous strengths, none greater than the dedicated and highly trained nurses, doctors, home care workers and other professionals who devote their lives to delivering care. At the same time, we face important challenges. For many years we have sustained health care by growing spending at six to eight per cent every year, far in excess of the economic growth that lets us pay for it. With a budget deep in deficit, we simply cannot afford to continue down this unsustainable path.

And despite all of the spending, and the enormous dedication of frontline health workers, we do not consistently get the results Ontario families expect and deserve. Far too many seniors wait for the home care or the long-term care they need. People with chronic diseases like diabetes and kidney disease get a tremendous amount of health care treatment, but their health results are often poor, even though we spend more than most countries. Everybody recognizes that it is more effective and less expensive to invest in prevention and wellness than treatment, yet every incentive in the system conspires to promote the exact opposite. And no matter how much we spend, or how committed individual nurses and doctors are, the system is often maddeningly frustrating to navigate.

The current government has approached these challenges with massive spending and good intentions. It says many of the right things: that we need more integration among hospitals, doctors and home care… that we need to bring care closer to home especially for seniors… that we can use evidence to provide better care. But the money has run out – even the government itself admits it can only afford to grow health spending at less than a third the rate of the last eight years. And the good intentions just haven’t delivered.

There’s a reason for this. The current government has taken a fundamentally flawed approach of preferring centralized, bureaucratic solutions, rather than supporting the people who actually deliver care on the ground. From eHealth to Local Health Integration Networks, this government has lavished billions on administrative agencies with no role in caring for patients. Nine years later we still don’t have doctors and hospitals using the same electronic health records, and we still don’t have integrated local health care.

When we look at the actual results we achieve – how healthy we are – and at how much we spend to achieve these results, we cannot say today that our health system is the best in the world. But it can be. We share many of the goals the current government claims to support. After all, who would disagree with a goal like helping seniors to remain at home? But we have a fundamentally different, and much more effective, approach to getting the job done. Our approach is based on putting resources and authority in the hands of people who actually deliver care, rather than bureaucratic agencies. It is based on transparency and accountability, even when that has the potential to embarrass ministers and administrators. And it is based on a laser focus on what will actually improve the health of you, your kids and your parents, while delivering the quality of service you expect and deserve.

While there are real challenges for health care in Ontario, I believe there are also tremendous opportunities. By putting our dollars where they will get the greatest value, by taking advantage of breakthroughs from medical evidence and technology, and by helping all the parts of our health system to work together, we can sustain our health system, provide better care for you and your family, and build a healthier Ontario.

Tim HudakLeader of the Official Opposition

Health care in Ontario is, quite rightly, one of the services we cherish most. We’re proud of our universally accessible system, which ensures our most vulnerable will receive care, and even prouder of the dedicated and talented health care professionals who provide it.

Despite our pride, most Ontarians know our system is coming under increasing strain and are anxious about how we can continue to sustain it into the future. We’ve heard we cannot continue to spend an additional six to eight per cent annually on health care, yet we are faced with an aging population that will require increasing amounts of health care in the next five to ten years. The “boomer tsunami” is almost upon us, yet very little has been done to prepare for it.

The truth is we only have a few paths to follow: increase taxes, decrease services or innovate. The Ontario PC Caucus believes innovation is the answer.

But what does innovation mean? In our view, there are several key themes that should guide us in developing a high-performing health care system for Ontarians.

First, we are currently operating our health care system on an outdated, reactive model based on acute episodes of illness. We need to transition to a twenty-first century model of care that is proactive and based on chronic disease management, health promotion and prevention.

The paths presented in this white paper suggest ways in which we can transition to this new model.

Secondly, we need to focus our attention on patients and families and ensure our new model of care centres around their needs and not the needs of health care providers. This will mean, for example, that people will have choice in home care services, that people will leave the hospital with a coordinated care plan, and that our mental health and addictions services will be accessible and coordinated.

Many people will suggest all of this will cost more money than we can afford, but the evidence suggests the opposite. In fact, when the delivery of care is centred around the patient, significant savings can be achieved.

The paths presented in this white paper suggest proposals to re-align our system, from reform of eHealth to health system navigators, which will get the best possible value from each health care dollar, while providing excellent care and high levels of patient satisfaction.

We hope the ideas presented in this white paper can start a meaningful health care discussion in Ontario, and look forward to hearing from you. You can contact me by email at [email protected] or by phone at 416-325-1331 (Queen’s Park).

Christine ElliottOntario PC Caucus Critic for Health

Christine Elliott, MPPD E P U T Y L E A D E R O F T H E O F F I C I A L O P P O S I T I O N ,M P P F O R W H I T B Y — O S H A W A

A Stronger Health System Starts with Telling the Truth

Getting Better Value Means Better Use of Evidence

New Challenges Require New Solutions

The Best Care is Usually Care Closest to Home

Fund the Health System to Work as a System

Make Care Easier to Access and to Understand

Make Mental Health an Integral Part of the Overall Health System

Recognize that Better Health is Not Just About Health Care

Provide Greater Patient Choice

Harness Competition to Get Better Service at Better Cost

Efficiency Today Allows Time to Get Long-Term Reforms Right

Conclusion

C O N T E N T S

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Yearly Ontario Health Care Spending

2002 2003 2004 2005 2006 20071998 1999 2000 2001 2008 2009 2010 2011 2012

Source: Ontario Ministry of Finance data, 1998-2012

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PAT H S T O P R O S P E R I T Y

A STRONGER HEALTH SYSTEM STARTS WITH TELLING THE TRUTHWe invest more in health care than in any other service, and rightly so. We rely on our health care system when we are at our most vulnerable, and great health care can mean the difference between pain and comfort, between anxiety and relief, and even between life and death.

We need a strong and continually improving health care system, not just today but in the decades to come. Ensuring a strong and improving health care system begins with telling the truth.

The truth is that for many decades, and especially in the last 30 years, the cost of our health system has been growing much faster than our ability to pay. Health costs have been growing by six to eight per cent a year, year after year, even though the economy has only grown at a little more than half that rate. Many studies, including the recent Drummond report, have demonstrated that it is not sustainable in the long run for our most important and expensive spending program to grow faster than our ability to pay every year, but the same conclusion is evident to anyone who has ever balanced a household budget.

The reason health spending has been growing so fast is not mainly that inefficiency has been growing. Nor is it the aging of the population. By far the biggest driver of rising health cost is that we are providing more health services to, say, the average 55-year-old man each year, than we did the year before, or the decade before that.

Some of this extra health care is helping a lot. For example, we have hip and knee replacements now that essentially didn’t exist 30 years ago. When people are relieved of pain and regain mobility, that’s a very good thing.

But overall, all of this extra health care isn’t making the health of the population in Ontario much better. We sometimes take comfort that Canada’s performance on health outcomes like life expectancy and infant mortality is better than the performance of the United States, but the truth is that plenty of countries achieve better health outcomes than we do, and most of them spend less.

In September 2012, the Ontario PC Caucus released a plan to get the foundation of our health system right, by putting the patient at the centre. That plan would address the excessive complexity and overlap in our health system by replacing the alphabet soup of bureaucratic agencies – from Local Health Integration Networks (LHINs) to Community Care Access Centres (CCACs) – with integrated “health hubs” run by people who actually deliver health care, like hospitals, doctors and nurses.

Infant Mortality(Deaths per 1,000 Live Births)

Source: Conference Board of Canada, data based on year 2009

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Life Expectancy(Years at Birth)

Source: Conference Board of Canada, data based on year 2009

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This paper builds on that foundation by proposing a set of specific steps we can take to build a higher-performing health system, while ensuring its sustainability in the years and decades to come. The proposals range from treating chronic disease as the leading health challenge of our time – and treating a person with multiple diseases as one patient, rather than many – to providing greater patient choice in selecting the home care you need.

No health system can provide and pay for every possible treatment in every possible situation, and no health system does. Even though our system purports to provide whatever treatment is medically necessary, in practice the government and health care providers restrict that.

Waiting lists are one obvious way: you can get your surgery, but not for a year, and you have to wait

Main Causes of Health Care Spending Increases(Average Annual Increase, Canada from 2000 to 2010)

Source: Canadian Institute for Health Information

7% Total Increase8%

6%

4%

2%

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GreaterUtilization

3.1%

Inflation2.7%

Population Growth1.2%

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six months for an MRI. There are other ways, like deliberately taking a long time to approve reimbursement of new drugs, or just not having new technologies, even though they have proven benefits.

The system sets priorities for what care is actually provided, but it does it in the wrong way. It’s set up to minimize transparency and accountability – to give as much cover as possible for the minister of health – rather than to maximize how healthy we can be.

We need to turn that on its head. We need our health system to invest our dollars in ways that will have the most impact in making people healthier. That means maximum transparency to make good decisions, rather

than minimum transparency to protect ministers and administrators.

It means rigorously assessing what actions – what prevention programs, what tests, what drugs, what surgeries, what home care services – actually do the most to improve or maintain our health. And it means acknowledging that cost is tremendously important in how we set priorities, rather than pretending that we don’t even think about cost and then secretly doing it behind closed doors. We want to maximize the health of patients – of people – which means maximizing the value of our health spending and getting the greatest quality of care for each dollar we spend.

- Jean-Marie Berthelot, VP, Canadian Institute of Health Information, October 2010.

The share [of the health budget] spent on Canadian seniors has not changed significantly over the past decade — from

43.6 per cent in 1998 to 43.8 per cent in 2008. While it is true that care is costlier for people who are 65 and older, we have

not seen a rise in the proportion we spend on seniors.

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GETTING BETTER VALUE MEANS BETTER USE OF EVIDENCEMost of the improvements we have achieved in health come from rigorously collecting and applying evidence. Understanding the germ theory of disease led to a revolution in public health, infection control and antibiotic treatments. Evidence on the linkage between obesity and diabetes has allowed doctors to intervene much earlier to help patients to manage their risk, as well as to include lifestyle modifications like exercise as a central element of treatment. There are literally thousands of similar examples, forming the basis for most health practices today.

Appropriate use of evidence can also help to change or eliminate treatments that are ineffective or even dangerous. There is ample evidence that antibiotic treatments are not effective for cold symptoms, yet surveys indicate they are sometimes prescribed. Some surgeries for back pain or arthritis have been shown to be no more effective than physiotherapy. Early disease management programs to help people with diabetes and asthma were supported by the best theories, but many did not actually produce measurable results. Recent evidence has called into question some common medical practices such as the early administration of “beta-blocker” drugs for heart attack survivors.

- Drummond Commission, page 170.

Evidence-based guidelines for the care of specific maladies or conditions… are needed to even out the

wide variety of treatments — some more effective than others — that are now used for the same problems. …Currently, it is unclear what objectives professionals

are expected to meet and accountability is weak.

“

”Yet experts are virtually unanimous that we do not collect enough of the evidence that could lead to better treatments, and we do not always apply what we learn. One of the most important steps in applying evidence to care is assembling patient databases or “registries” that keep track of thousands of patients with similar conditions, what treatments they got and how their health progressed afterward, with the patients’ names and personal details deleted to protect privacy. Researchers and clinicians then examine the results and change practices based on what is proven to work.

Sweden has done a particularly thorough job of building patient registries and has been rewarded with significant improvements in measures ranging from 30-day survival after heart attacks to the rate of complications in cataract surgeries. The current Ontario government has done too little to build the patient registries that can enable evidence-based care, and recently abandoned its efforts to build a diabetes registry. This has to change.

To get better value, we need evidence not only on outcomes – which treatments actually lead to better results – but also on cost. Amazingly, when the Ontario government collects data on the cost of a surgery, it doesn’t include the

cost of the surgeon, because the surgeon is paid through the OHIP budget instead of the hospital budget. If we want to get the best value for our health dollars, we need reliable evidence on how much treatments cost, including follow-up costs like hospital re-admissions.

Finally, we need to apply the evidence we gather. In some areas, like surgical techniques, the role of the Ontario government is primarily to get evidence into the hands of practitioners through a much more effective Health Quality Ontario.

PATH 1Focus health care decisions on evidence, to achieve greater quality per dollar spent. Dramatically enhance patient databases to enable doctors and researchers to improve treatments and prevention programs based on real-world evidence. Require drug and medical device manufacturers to provide proof of incremental value when seeking reimbursement. Move more quickly to make innovative new drugs and devices available, while requiring better cost effectiveness if manufacturers cannot prove superior effectiveness or safety.

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In others, like drug reimbursement, the government needs to make decisions differently. When a new drug comes onto the market, if the manufacturer wants the Ontario Drug Benefit program to pay a higher price for it, that manufacturer should be required to produce evidence not only that the drug is effective and safe, but also that it is more effective and safe than other therapies, at least for some patients. And when post-market surveillance provides additional insight on the benefits and risks of drugs, this should be considered in decisions about whether to continue, enhance or discontinue reimbursement.

Governments in many countries, like the United Kingdom and France, have already adopted this approach, but Ontario has lagged. Instead, Ontario is slow to cover all new drugs, so those that genuinely represent breakthroughs, like some new cancer drugs, aren’t available to patients. This one-size-fits-all approach wastes money and denies patients the best available care.

Patients Have More Complexity as They Age

Age

One DiseaseTwo DiseasesThree DiseasesFour + Diseases

45-64 65-79 80+

Source: : Healthcare Quarterly, "Population patterns of chronic health conditions, co-morbidity, and healthcare use in Canada,” 2008.

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NEW CHALLENGES REQUIRE NEW SOLUTIONS The kind of health care people need is changing, in part because of the past successes of our health system.

More and more people today are living with two, three, four or more chronic conditions, like heart disease and diabetes and chronic kidney disease. That’s not because our health system has failed. In fact, it’s because it has succeeded. Fifty years ago few people survived a chronic condition long enough to acquire three or more.

Early in the twentieth century, we achieved the biggest improvements in outcomes like life expectancy in human history, mainly by managing infectious disease. Some of the measures to achieve that didn’t involve health care at all: the most important were clean water and better sanitation. But even the advances in the health system were in areas like vaccinations and antibiotics, which were highly effective and relatively inexpensive.

By the middle of the twentieth century, the biggest challenges were changing. Once water is clean, you can’t fight disease by making the water even cleaner. Once smallpox is eradicated, the vaccine can’t make any further improvements in health. As people lived longer, we needed hospitals and more advanced acute

care to manage the heart attacks, cancer, and other conditions that became the most important frontiers of health care once the burden of infectious disease was significantly reduced.

Now, the biggest challenge for our health system is changing once again. When our acute care system

works well enough that more people are surviving heart attacks, more of us live with heart disease. When better surgeries allow fractured hips to be repaired and joints to be replaced, people live longer with the consequences of impaired mobility. Longer life expectancy leads to more of the diseases that come with age, from diabetes to emphysema to Alzheimer’s disease. And just as we couldn’t deal with acute conditions through even more clean water, we can’t manage chronic disease with even more acute hospital care.

Chronic disease is the most significant challenge our health system faces, from the perspective of both results and costs. People with multiple chronic conditions unfortunately have quite poor health outcomes, even

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The Ontario government has not developed or implemented directives about the actual delivery of

health care or the way in which that care is organized and delivered, which includes chronic disease management. Financial incentives (rather than directives) have been utilized. The Ontario Chronic Disease Prevention and Management Framework then remains just that – a

framework – without an implementation plan or the resources to support it.

“

”though they use a huge amount of health care. The 170,000 patients with the most complex chronic disease use $9 billion in health care in Ontario each year; the 500,000 patients who are the next most complex use another $9 billion.

Our health care system is not set up to provide the best care for people with serious chronic conditions, and especially those with multiple chronic conditions. We rightly rely on family doctors to be the gateway to the health system, but for the one to two per cent of patients with the most complex needs, a family doctor without additional support often doesn’t have the resources to manage all of a patient’s different specialists, tests, hospital and clinic visits, and medications.

The medical profession is mainly set up around diseases – one doctor to deal with kidney disease and another to deal with diabetes – but we are just at the beginning of building expertise in how to manage all of these diseases

in the same patient. Even clinical trials typically screen out patients with multiple conditions because the extra conditions make analysis too difficult, but this means that we often have very little evidence about what works for the patients who are the most intensive users of health care. We need a new, integrated, evidence-based approach to care that is tailored specifically to the needs of people with multiple chronic diseases.

This offers an encouraging opportunity because there is considerable evidence already that for people with chronic health conditions, the best care is often significantly less expensive than what we provide today. In particular, the best care is usually provided close to home – through community clinics and home care. But people with complex chronic conditions frequently end up in acute care hospitals – especially emergency rooms – even when they don’t have acute problems. Waiting in an emergency room is inconvenient and disruptive for these patients, and expensive for the

Source: McMaster Health Forum, Strengthening Chronic Disease Management in Ontario, October 2009.

Chronic Disease is the Most Significant ChallengeOur Health System Faces

Patients with Most Complex Disease

170,000

500,000

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Patients with NextMost Complex Disease

$53,000

$9 Billion Total $9 Billion Total $30 Billion Total

= $18,000

13,000,000All other Ontarians

= $2,300per patient per patient per patient

PATH 2

PATH 3

Build a system that treats chronic disease as the leading health challenge of our time, not as an afterthought in a system designed around acute care. Build on the unique assets of Ontario’s chronic hospitals, along with family doctors and community-based care, to pioneer a truly integrated approach to health for patients with chronic conditions. Focus on providing community and home-based care options to help these patients to live better at home, and to avoid unnecessary acute hospital visits. Create one or more centres of excellence to develop evidence-based approaches to care for these patients, including those living with two, three or more health conditions.

Ensure that every patient with chronic conditions has a comprehensive care plan, and provide dedicated care navigators – such as nurses – for the patients with the highest needs. Treat a patient with multiple conditions like one patient, not many.

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system, especially when they don’t need the specialized capabilities that only an emergency room can provide. Moreover, vulnerable patients can be exposed to risks like hospital-acquired infections.

These patients don’t go to the emergency room because they are being irresponsible. It’s often because the system isn’t set up to give them good alternatives. For example, for people with conditions like mobility challenges, rehabilitation therapy is often more beneficial and much less expensive than a visit to an acute hospital. Yet rehab hospitals today are often not set up to admit a patient who has not gone to an acute hospital first, even if that acute visit is completely unnecessary. This has to change.

Since care is fragmented, patients with complex conditions often do not have a comprehensive care

plan that covers all of the different specialists and all of the different sources of care they access. Without a comprehensive care plan, there is little hope of coordinating the patient’s overall care – even with an electronic health record, which is only a record rather than a plan.

We simply must support health professionals to work together to develop integrated care plans for patients that need to see multiple doctors and use multiple sources of care. And for patients with the highest needs, we must provide a dedicated care navigator – most often a nurse – who can actively coordinate the plan, ensuring that a patient doesn’t get the same test three times, and that she isn’t scheduled for physiotherapy at home at the same time as she is supposed to be getting an x-ray across town.

PATH 4Shift resources and incentives to promote care closer to home, particularly by expanding home care and long-term care availability, and by promoting more types of care in the home. Allow pharmacists, paramedics, nurses and nurse practitioners to provide more types of advice and treatment where these are most convenient and beneficial for patients, updating scope of practice where required.

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THE BEST CARE IS USUALLY CARE CLOSEST TO HOMEFor people with chronic disease, and even for seniors in relatively good health, we need to recognize that the best care is often the care provided in the home or closest to home.

The foundation of a top performing health care system is ensuring that everyone has access to a great family doctor or nurse practitioner. Not only is your family doctor the first person you see for most health conditions; family medicine plays a critical role in co-ordinating what all of the other parts of the system do for you, like keeping track of multiple medications you may be prescribed by different specialists. We need to support excellent family health care with tools like functioning electronic health records, with education and evidence, and with the flexibility to provide care in new ways, such as advice over the phone, or home visits.

Good home care, like personal support, physiotherapy and home nursing not only allows seniors to stay in their homes rather than having to move, but it can also keep them in significantly better health. For example, they are exposed to considerably lower risk of influenza and other infections. Over time, we need to restructure our health system and take advantage of new technology to allow even more care to be provided in the home, from home doctor visits to remote advice on medications and emerging technologies like home dialysis.

When people cannot remain at home, they deserve access to a long-term care facility designed for people to live in it for months or longer, not a hospital bed intended for a short, acute stay.

While we cannot rely on funding more of everything at a time when we simply do not have the money, we must deliver more of the services like home care and long term care that keep people healthier, and away from unnecessary hospital visits. This in turn allows hospital beds to be used for people who really need the full services of a modern hospital for surgery or an acute condition, reducing wait lists and pressures on hospital budgets.

Providing care closer to home can also mean taking advantage of existing resources, like pharmacists and paramedics, to deliver better access to advice and appropriate therapies. For example, pharmacists are often available 24 hours a day and can provide advice on relevant therapies in areas such as smoking cessation. Nova Scotia has had great success in expanding the scope of practice for rural paramedics to allow them to treat appropriate patients rather than always transporting them to see doctors. This has significantly increased the number of patients that can be treated within long-term care facilities rather than making a trip to an acute hospital.

PATH 5Fund the health system to work as a system. Allow health hubs greater flexibility to direct funding to the actions that have the greatest impact on health in the long run, from prevention programs like smoking cessation, to intensive rehabilitation and home care to reduce hospital readmissions. In the long term, move towards funding the health of a population cared for by a hub, rather than funding individual treatments.

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FUND THE HEALTH SYSTEM TO WORK AS A SYSTEMOur health care system too often fails to function as a true system, not just for people with the highest health needs, but for all patients.

Our earlier paper, Paths to Prosperity: Patient-Centred Health Care proposed a plan to create an integrated system through health hubs. These would be run by organizations that actually deliver care and would replace overlapping layers of administration from LHINs to CCACs. At the same time they would strengthen the home care and other services currently delivered through CCACs. The paper also introduced the idea of patient-centred funding for hospitals and for health hubs.

Although the government is moving too slowly, the version of patient-based funding it is implementing today represents an important step forward from the outdated system of the past. Historically, funding for hospitals was based on lump sum global budgets, which treated patients only as a cost. Under the new system, funding will follow patients so that hospitals that provide more services get more funding.

The government’s first step could more accurately be described as “treatment-based funding” because it still focuses on the treatments that each institution provides for the patient, rather than on the patient’s actual health. For example, if a patient appropriately gets physiotherapy at home instead of a hospital visit, the hospital loses funding. While we still expect that hospitals will do the right thing, it is still not helpful to provide a disincentive to direct patients to more appropriate care. If a wellness program for a patient with diabetes can delay or avoid that patient ever having kidney failure and needing dialysis, surely we would

prefer to direct funding to that wellness program, rather than penalizing a hospital that runs the dialysis clinic.

One of the most important benefits of creating integrated health hubs is to bring together the whole system of care from clinics to hospitals to home care and rehabilitation. Each hub will be responsible for a defined population of patients and will look after all of those patients’ health needs. In the short term, this will allow hubs to make better choices about the settings in which care is provided – like an urgent care clinic to reduce emergency room waits – because they will be responsible for all of the costs and all of the funding.

Once we build the right foundation over the next decade, we can move to funding hubs based on the health of the populations they serve, rather than the treatments they provide. This will allow hubs even greater flexibility to invest in prevention and wellness programs, and the health procedures that have the greatest long-term impact on people’s health, without fear of being penalized because healthy people need fewer treatments.

Among Ontario’s greatest strengths is its diversity, and this is reflected in the diversity of our health system. Our public health care providers include many with religious and cultural roots. As we integrate our universal, public health care system into hubs, we can and should continue to respect the religious and cultural heritage of those parts of the system.

PATH 6Make care easier to access and to understand. Rigorously measure satisfaction with the patient experience and communication, and tie managers’ incentives to the scores. Break down the barriers that separate CCACs, LHINs, family doctors and hospitals, providing a single point of accountability for your care regardless of where it is provided.

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MAKE CARE EASIER TO ACCESS AND TO UNDERSTAND While the purpose of our health care system should be to help us be as healthy as possible, it must also be understandable and easy to access. Too often, patients and families are faced with immense frustration and anxiety when they try to get the care they need. That’s not acceptable, and even worse, it sometimes leads to people not getting the right care at all.

For everyone who uses the health system, we need to make clear communication and excellent service a core value. That means measuring satisfaction with the patient experience, holding managers accountable and rewarding those who deliver great communication and a great patient experience. It also means giving patients tools, like access to real-time information about emergency room wait times online and through Telehealth Ontario.

The people with the most complicated health needs, like congestive heart failure and dementia, have the greatest challenges in accessing the right care at the right time. We need to provide much more help with navigating the health care system. As noted earlier, this requires a dedicated professional such as a nurse,

who talks to the patient or her caregiver directly and is responsible for ensuring that the patient’s family doctor, specialists, tests, physiotherapy and hospital visits all work together. There is a cost to providing this service and it is not feasible to do it for every patient, but for those with the highest health needs – often seniors – there is ample evidence that good care navigation not only improves outcomes, but saves money overall.

Of course, the most fundamental element of accessible health care is having a family doctor. We will continue to work to ensure access to family doctors, especially in northern and rural areas, and will remove barriers to Ontario residents or others trained in quality global medical schools who wish to practice in Ontario.

Economic Costs of Mental Health and Addiction

*For example, the costs of hospitalizations, substance abuse programs, law enforcement, supportive housing, etc

Sources: W. Gnam, “The Economic Costs of Mental Disorders and Alcohol, Tobacco, and Illicit Drug Abuse in Ontario, 2000,” 2006, Centre for Addiction and Mental Health Fact Sheet; and

Ministry of Health and Long-Term Care, “Every Door is the Right Door: Towards a 10-Year Mental Health Strategy,” 2009.

Productivity Loss

74%

DirectCosts*26%

$39 Billion

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MAKE MENTAL HEALTH AN INTEGRAL PART OF THE OVERALL HEALTH SYSTEMThe brain is the most complex organ in the human body, and health conditions that affect the brain can be among the most debilitating and challenging that any of us can ever face. Yet mental health has for too long been treated as an afterthought in our health system. People suffering with mental illness have too often faced misunderstanding and even blame, rather than compassion and effective treatment.

Suicide is the second leading cause of death in young people aged 15 to 24. How can we explain to a parent whose child is contemplating suicide that care is available only after a two-year wait? The adults most in need of care often cannot access mental health services, especially if they have serious physical health conditions, because no one in today’s system is equipped to manage their complex needs.

No part of our health system is more in need of change.Don Drummond estimated in his 2012 report on public service reform that the economic costs of mental health and addiction issues in Ontario are $39 billion. Seventy-four per cent of those costs – $29 billion – were related to a loss of productivity in the workplace, and $10 billion were directly related to multiple hospitalizations, community mental health and addictions programs and involvement in the criminal justice system, among others.

But the economic case for change if anything obscures the pain that every day afflicts those living with mental health conditions, and the frustration and anguish of families who cannot access the care and support they so desperately need. We are simply not doing enough to support our children, youth and adults living with significant mental health and addictions challenges.

Lack of integration is a critical issue throughout our health system, and nowhere more so than in mental health. Ontario’s Select Committee on Mental Health and Addictions noted in its August 2010 report that “one of the main problems in Ontario’s mental health and addictions system is that there is, in fact, no coherent system. Mental health and addictions services are funded or provided by at least 10 different ministries. Community care is delivered by 440 children’s mental health agencies, 330 community mental health

PATH 7Treat mental health as equal in importance to physical health. Ensure fragmented elements of adult and children’s mental health and addictions treatment in Ontario are integrated into a coherent province-wide plan. Recognize children’s mental health as part of the health care system. Better integrate the diagnosis and treatment of mental health conditions from depression to dementia with the physical health conditions that frequently occur in the same patients, at the same time.

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agencies, 150 substance abuse treatment agencies and approximately 50 problem gambling centres.

Yet no one has the ultimate responsibility for coordinating these services or for measuring their results. That, combined with the stigma still surrounding mental health and addictions, creates barriers to change beyond those faced by physical health issues.

We have a wealth of knowledge and experience in the field of mental health and addictions in Ontario,

but we are not taking advantage of it by listening to experts, building sufficient capacity and organizing our resources effectively.

For example, many Ontario families with children facing serious mental health and addictions challenges, such as severe eating disorders and personality disorders, are forced to seek residential treatment in the United States. Families can sometimes receive $75,000 or more in OHIP funding for these services, yet must strain their own family budgets to pay tens of thousands of dollars in additional costs for the services and to send their children out of the country. We could provide better services at lower cost in Ontario. Right now the Ministry of Children and Youth Services is responsible for children’s mental health in Ontario and the Ministry

of Health pays for the expensive residential programs in the United States. This means no one is empowered to fix a patently absurd system that wastes money while hurting patients and their families.

While we sometimes talk about mental health care as if it were a single service, in fact it encompasses a wide variety of needs. These range from the needs of dual diagnosis patients – people with developmental challenges and mental illness – to those of people managing addictions or specific challenges like eating

disorders. We need the appropriate capacity in our mental health system to deal with each of these issues in children, youth and adults.

We must recognize that mental health care is as important as physical health care. True patient-centred health care recognizes that the brain is the central organ in the body, and therefore embraces a “mind-and-body” approach. Patient-centred health care recognizes that the people with serious physical health conditions like cancer and heart disease are the most likely to face mental health challenges like depression at the same time, and that management of the mental health conditions is deeply related to physical health recovery.

One of the main problems in Ontario’s mental health and addictions system is that there is, in fact, no coherent system. Mental health and addictions services are funded or provided by at least 10 different ministries. Community care is delivered by 440 children’s mental health agencies, 330 community mental health agencies, 150 substance

abuse treatment agencies and approximately 50 problem gambling centres.

“

”-Ontario Select Committee on Mental Health and Addictions, Final Report, 2010.

PATH 8Recognize that health care is not the only contributor to health. Through 45 minutes of mandatory daily physical activity in schools, and smarter use of social and economic policy, improve prevention and wellness, ultimately reducing unnecessary use of health care and building a healthier Ontario.

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RECOGNIZE THAT BETTER HEALTH IS NOT JUST ABOUT HEALTH CAREAlthough health care is the biggest and most expensive program the Ontario government funds, the truth is that the health care system is not the most important or the most cost effective determinant of how healthy we are.

There is overwhelming evidence that education, economic growth, housing and many other economic and social factors have a much bigger impact on how healthy we are than the health care system does. One implication of this is that good economic and social policy is good health policy. This is one more reason why it is so important to accelerate job creation, to raise family incomes especially among the working poor, to move people from welfare to work, and to ensure that our education and training system helps people get the skills they need to find and keep a good job.

It also means that in some situations, the best investments to improve health may not be in the health care budget. For a person with serious mental illness who becomes homeless and repeatedly goes to the emergency room, a smart investment in supportive housing is critical, along with good community-based mental health services. These can actually save the health system money, since that patient’s visits to the emergency room can be much more costly than housing and community services.

Ontario families also understand the best approach to health is to stay healthy in the first place. There are important wellness and prevention programs that can and should be managed by family doctors and other health providers, such as smoking cessation programs. However, one of the most important contributions we can make to a healthy Ontario is to ensure our kids get enough daily physical activity, and the best place to do that is at school.

Physical education and health classes, led by a qualified physical education teacher, play a critical role both in students’ health and in their education. Yet it is neither practical nor necessary to replace other subjects during

the school day with more physical education. Instead, we should require that every child enrolled in school participate in 45 minutes of mandatory physical activity each day, in addition to curriculum-based physical education classes. This would be phased in starting with students in grade seven and above. Except those exempted for medical reasons, it would be an obligation for all students, like attending class and coming to school on time. Boards would be permitted to recognize organized physical activity through community sports, like a local soccer league as long as students participate in a minimum amount of organized physical activity every school day.

In many cases, dedicated teachers provide their time to supervise school sports. Many would be delighted to see more students take advantage of these opportunities. But to ensure that all students can participate in daily physical activity, we will eliminate the barriers in insurance arrangements and collective bargaining agreements that prevent appropriately screened community volunteers from supervising sports and fitness.

We can also help to give our students the right start by giving them the knowledge they need to lead a healthy life. This goes beyond lecturing students on topics like nutrition to helping them to understand the science of human health. Health is a valuable and vigorous area of science. There is a reason why a Nobel Prize is awarded in medicine. Our students deserve an introduction to health science just as much as physics and chemistry. Building on the valuable content already in the science curriculum on biology, we should offer a more thorough grounding in human health science, from physiology to epidemiology.

PATH 9

PATH 10

Give patients more choice in the health services they receive. Allow patients receiving non-clinical home care services like housekeeping and personal support to choose whether to have a care provider purchase home care for them, like CCACs do today, or whether to use the same money to hire their own home care.

Encourage everyone in Ontario to have an end-of-life plan specifying his or her wishes if incapacitated, from preferences about care, to who should make care decisions, to organ donation.

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PROVIDE GREATER PATIENT CHOICEWe all rely on the expert judgment of doctors, nurses and other professionals to help us to get the right health care for our needs. At the same time, patients and their family members make important choices about their own health care all the time. We choose what emergency room to go to in a city with multiple hospitals or whether we want heroic measures taken if we are faced with a terminal illness. Our health system needs to do a much better job of supporting patients and families in making choices.

In some cases, what is needed is better information. For example, there is no reason you shouldn’t be able to find out the expected wait times for emergency rooms or urgent care on the internet or through Telehealth Ontario before you leave for the hospital or a clinic.

In other situations, we need to recognize that patients and families really are in the best position to make decisions about what they need. For example, if a senior needs more frequent visits from a personal support worker, but doesn’t need help with meal preparation, she and her family should have the flexibility to make sure the available home care money is spent in the best possible way. That includes allowing them to opt out of the government-provided services currently organized by CCACs and to use the equivalent money to choose another qualified home care provider. Where possible, it also means providing support to family members who choose to work part time or to take

time off work to provide care for a relative, instead of relying on government-funded home care workers to provide that care.

We sometimes need to plan ahead for our health care choices, and this is particularly true for end-of-life care. Through better online resources and training and support for health professionals, we should strive to meet the goal of everyone in Ontario having an end-of-life plan. These plans outline what kinds of care you want to receive in situations like a terminal illness. They also designate who should make care decisions for you if you are incapacitated, and your preferences on matters like organ donation. They do not in any way restrict the care to which you have access. Instead they ensure your wishes are respected if you are ever in a situation where you can no longer communicate what they are.

PATH 11For appropriate services, use competitive tendering to ensure the best value for our health care system. When expanding clinical services that need not be provided in a hospital, such as MRI scans, dialysis treatment and high-volume, less complex surgeries, conduct a transparent tendering process and select providers that can offer the best quality and most cost-effective service.

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HARNESS COMPETITION TO GET BETTER SERVICE AT BETTER COSTSome people talk about competition in health care as if it were a sinister force, at odds with the public good. Yet appropriate competition plays a very important and beneficial role in health care today.

Doctors compete for patients, and patients have the right to seek a different doctor if they are not satisfied with the service they are getting. That’s a good thing.

When we build a new hospital, it would be a scandal if we didn’t put the building project out to tender to get the best proposal at the best price.

Certainly there are some areas in health care in which the wrong kind of competition is not helpful. For example, while researchers compete for grants, it’s extremely important that they ultimately share the results of their publicly-funded research for everyone’s benefit.

However, there are opportunities to expand the use of productive competition within our health care system, to get better service at better cost. We should take full advantage of these. Hospitals and other health institutions frequently tender for non-clinical services like cafeteria service already. We would build on existing best practices by requiring them to seek competitive bids for all relevant non-clinical services like IT, just as we propose for the rest of the public sector.

For clinical services that can be provided outside a hospital or physician practice, we can also use well-established tendering processes to ensure we get the best service at the best price when expanding system capacity. These would include services like MRI tests, dialysis services and high-volume, less complex surgeries such as cataract surgeries, hernia repairs and simple joint replacements. Performing these procedures in a specialized clinic rather than a hospital is increasingly recognized as a best practice. It can lead to higher quality service without some of the unique risks associated with hospital admissions. It can

There should not be... an ideological bias towards

public- or private-sector service delivery. Both options should be fully tested to see which provides the best service. This should not be defined simply with respect to

cost, but be quality-adjusted.

“

”-Drummond Commission, page 175.

also be much more convenient for patients, reducing the length and uncertainty of wait lists. In addition, it often allows this excellent care to be provided with a lower cost structure.

Of course, in many cases, the existing providers of these services may be able to offer the best proposal. After all, they have the benefit of experience, and in some cases of scale. But we cannot simply assume that every existing provider will automatically deliver the best value, any more than we could make that assumption about air ambulance service.

For services where tendering is possible, clear proposals and a transparent process represent the best way to get the best service and the best value. Initially, the government will sponsor these competitions, and once health hubs are fully operational, they will take over the responsibility.

Yearly Ontario Health Care Spending(As a proportion of total government expenses)

Source: TD Economics, “Charting a path to sustainable health care in Ontario,” Special Report, May 27, 2010.

2010 2030

Health Care

Everything Else54% Everything Else

20%

46%Health Care80%

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EFFICIENCY TODAY ALLOWS TIME TO GET LONG-TERM REFORMS RIGHTFor all of the reasons we have described, we need thoughtful but fundamental reform to strengthen our health system and to make it financially sustainable in the long term.

The system needs to focus on value, and we need good evidence on both quality and costs to achieve that. It needs to be much more integrated: a true system, with the patient at the centre. It needs to be more effective in prioritizing prevention to both to avoid disease in the first place, and to prevent it from getting worse. It needs to recognize that a person with diabetes, early-stage Alzheimer’s and heart disease is one patient, not three. We need to recognize the unique needs and challenges of northern and rural health systems, from attracting qualified professionals, to using technology to make care more available in remote locations. We need much better information systems including patient records. And we need the right mix of different types of care, including more care in the home and in the community.

We cannot make the health system effective and sustainable in the long term solely through making it more efficient – through ever-lower administrative costs and ever-lower pay for workers. That’s why we need real reform to strengthen the system. But getting that reform right will take time and, in the short term, we can sustain the system by making one-time gains in administrative efficiency and by taking a temporary pause in wage increases.

While administration is not the biggest driver of growth in the health system, we spend billions on it every year and any waste is too much. By eliminating LHINs and the administrative component of CCACs in favour of health hubs that will actually deliver better care, we can redirect millions of dollars from administration to patient care. And more importantly, we can avoid the waste of literally billions of dollars that the current government has directed towards failed, out-of-control agencies like Ornge and eHealth Ontario.

eHealth Ontario has been a failure, spending $2 billion on administration and consultants without producing results and, perhaps more tragically, delaying the progress health providers could have been making in actually implementing existing electronic health records solutions that would have benefitted patients. Electronic records are tremendously important because they allow all of a patient’s health status and history to be shared with all of the people involved in delivering care, eliminating duplicate tests, uncovering potential drug interactions and preserving vital information about how the patient has repsonded to therapy in the past. A single electronic health record also provides a better opportunity for family doctors to share all of a patient’s health information with the patient.

PATH 12

PATH 13

Create time to achieve fundamental strengthening of our health system by making one-time improvements in efficiency today, such as eliminating administration in LHINs and CCACs, while strengthening the home care services currently organized by CCACs, and by temporarily pausing cost inflation through an across-the-board wage freeze.

Deliver on the electronic health records that are mission-critical for better health quality, by putting control of the eHealth initiative in the hands of the hospitals and doctors who actually use health records. Conduct a focused value-for-money audit to determine what eHealth has actually produced with the $1 billion it spent since the Auditor General’s report in 2009. Give oversight of all future funding to a board of health providers. Enable them to include off-the-shelf and open-source components while ensuring an effective province-wide records system and to hold eHealth administrators accountable for delivering on time.

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In 2009, the Auditor General issued a special report on eHealth, concluding that “Ontario taxpayers [did] not receive value for money for this $1 billion investment.” Since then, the pace of spending has accelerated, but the pace of results has not. Government figures say that a further $1.06 billion has been spent on eHealth since the Auditor’s report in 2009. Yet we still do not have province-wide electronic health records, and critical initiatives like the Diabetes Registry and the Drug Information System have been either cancelled or delayed.

This failure was utterly predictable. As with the LHINs, the government created a layer of administration that was not accountable to the hospitals, doctors and other health providers who actually need to use the health records. And after the government was told in 2009 that this initiative had failed completely, its response was to double down on the same failed approach.

We will put control of the eHealth initiative in the hands of the hospitals and doctors who will actually use electronic health records, rather than allowing eHealth to continue as a top-down agency accountable to nobody.

After conducting a focused value-for-money audit to evaluate what concrete progress eHealth Ontario has actually made with its second billion in funding, we will put all further funding in the hands of an oversight board composed of the health providers who desperately need the records eHealth Ontario

is supposed to produce. We anticipate that they will insist on greater flexibility to include off-the-shelf and open-source solutions, while ensuring that all records in Ontario are interoperable (meaning that all of the different parts of the health system – family doctors, specialists, hospitals, pharmacists and so on – can seamlessly share the same information). They will also be empowered to hold administrators accountable for delivering on time. As health hubs get up and running, they will jointly take over this oversight role.

At the same time as we fix out-of-control provincial agencies, we will encourage and enable hospitals and other health providers to achieve greater efficiencies in their own administration through combined procurement, and through further shared “back-office” services like information technology and finance.

Finally, we must recognize the biggest driver of cost increases besides utilization growth is wage inflation. Over time, compensation for our capable and dedicated nurses, physicians and health workers can and should grow along with other wages in the economy. But at a time when Ontario faces a deficit of over $10 billion and private sector wages have stagnated, we simply cannot afford to go back to six per cent and eight per cent budget increases every year. While we make the long-term changes that will make our health system stronger and more sustainable, we will implement a temporary wage freeze for health care workers as part of a comprehensive public sector wage freeze.

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CONCLUSIONWhile Ontario faces important challenges in sustaining and improving our health care system, we also have an enormous opportunity.

By moving care closer to home, we can shorten wait lists for home care and long-term care, and fund a significant part of the shift by reducing unnecessary hospital visits. By rigorously applying evidence to our health care choices, we can replace treatments that do more harm than good, more quickly fund new drugs that fight cancer better, and make Ontario a global centre for innovation in higher value care.

By empowering health hubs to put the most important decisions in the hands of the hospitals, doctors and community health providers that actually deliver care, we can direct resources from treatment to prevention and wellness, and overcome the silos that too often prevent patients from getting the care they need.

We cannot continue down the path of trying to solve all of our health care problems by throwing money at them, hoping that more of the same will produce a different result. Not only do we not have the money to pay for it; the truth is that this approach has actually gotten in the way of needed improvements in care.

Making chronic disease a priority and treating it in the community doesn’t cost any more than the current approach, but it will improve the lives of people with diabetes and heart disease much more than additional hospital beds would. Directing funding to hospitals and clinics that can demonstrate the best results for the dollar is the right thing to do, no matter how much money we have.

All of the proposals in this paper are focused on one goal: helping you and your family to be as healthy as possible. Some of the choices to get there are difficult, while others seem so obvious that it’s hard to imagine why they haven’t happened already.

With the courage to make those choices, and with the support of the dedicated professionals who make our health their life’s work, we have complete confidence that our best, and healthiest, days are ahead.

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PATH 1

PATH 2

PATH 3

PATH 4

Focus health care decisions on evidence, to achieve greater quality per dollar spent. Dramatically enhance patient databases to enable doctors and researchers to improve treatments and prevention programs based on real-world evidence. Require drug and medical device manufacturers to provide proof of incremental value when seeking reimbursement. Move more quickly to make innovative new drugs and devices available, while requiring better cost effectiveness if manufacturers cannot prove superior effectiveness or safety.

Build a system that treats chronic disease as the leading health challenge of our time, not as an afterthought in a system designed around acute care. Build on the unique assets of Ontario’s chronic hospitals, along with family doctors and community-based care, to pioneer a truly integrated approach to health for patients with chronic conditions. Focus on providing community and home-based care options to help these patients to live better at home, and to avoid unnecessary acute hospital visits. Create one or more centres of excellence to develop evidence-based approaches to care for these patients, including those living with two, three or more health conditions.

Ensure that every patient with chronic conditions has a comprehensive care plan, and provide dedicated care navigators – such as nurses – for the patients with the highest needs. Treat a patient with multiple conditions like one patient, not many.

Shift resources and incentives to promote care closer to home, particularly by expanding home care and long-term care availability, and by promoting more types of care in the home. Allow pharmacists, paramedics, nurses and nurse practitioners to provide more types of advice and treatment where these are most convenient and beneficial for patients, updating scope of practice where required.

PATHS TO PROSPERITYA H E A LT H I E R O N TA R I O

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PATH 5Fund the health system to work as a system. Allow health hubs greater flexibility to direct funding to the actions that have the greatest impact on health in the long run, from prevention programs like smoking cessation, to intensive rehabilitation and home care to reduce hospital readmissions. In the long term, move towards funding the health of a population cared for by a hub, rather than funding individual treatments.

PATH 6Make care easier to access and to understand. Rigorously measure satisfaction with the patient experience and communication, and tie managers’ incentives to the scores. Break down the barriers that separate CCACs, LHINs, family doctors and hospitals, providing a single point of accountability for your care regardless of where it is provided.

PATH 7

PATH 8

PATH 10

PATH 9

Treat mental health as equal in importance to physical health. Ensure fragmented elements of adult and children’s mental health and addictions treatment in Ontario are integrated into a coherent province-wide plan. Recognize children’s mental health as part of the health care system. Better integrate the diagnosis and treatment of mental health conditions from depression to dementia with the physical health conditions that frequently occur in the same patients, at the same time.

Recognize that health care is not the only contributor to health. Through 45 minutes of mandatory daily physical activity in schools, and smarter use of social and economic policy, improve prevention and wellness, ultimately reducing unnecessary use of health care and building a healthier Ontario.

Encourage everyone in Ontario to have an end-of-life plan specifying his or her wishes if incapacitated, from preferences about care, to who should make care decisions, to organ donation.

Give patients more choice in the health services they receive. Allow patients receiving non-clinical home care services like housekeeping and personal support to choose whether to have a care provider purchase home care for them, like CCACs do today, or whether to use the same money to hire their own home care.

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PATH 12Create time to achieve fundamental strengthening of our health system by making one-time improvements in efficiency today, such as eliminating administration in LHINs and CCACs, while strengthening the home care services currently organized by CCACs, and by temporarily pausing cost inflation through an across-the-board wage freeze.

PATH 13Deliver on the electronic health records that are mission-critical for better health quality, by putting control of the eHealth initiative in the hands of the hospitals and doctors who actually use health records. Conduct a focused value-for-money audit to determine what eHealth has actually produced with the $1 billion it spent since the Auditor General’s report in 2009. Give oversight of all future funding to a board of health providers. Enable them to include off-the-shelf and open-source components while ensuring an effective province-wide records system and to hold eHealth administrators accountable for delivering on time.

PATH 11For appropriate services, use competitive tendering to ensure the best value for our health care system. When expanding clinical services that need not be provided in a hospital, such as MRI scans, dialysis treatment and high-volume, less complex surgeries, conduct a transparent tendering process and select providers that can offer the best quality and most cost-effective service.

Please let us know what you think by contacting us at:

[email protected] 416-325-1331

Room 436, Main Legislative BuidlingToronto, ON, M7A 1A8

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A Healthier Ontario